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Abstract

Background

The PELICAN Multidisciplinary Team Total Mesorectal Excision (MDT-TME) Development
Programme aimed to improve clinical outcomes for rectal cancer by educating colorectal
cancer teams in precision surgery and related aspects of multidisciplinary care. The
Programme reached almost all colorectal cancer teams across England. We took the opportunity
to assess the impact of participating in this novel team-based Development Programme
on the working lives of colorectal cancer team members.

Methods

The impact of participating in the programme on team members' self-reported job stress,
job satisfaction and team performance was assessed in a pre-post course study. 333/568
(59%) team members, from the 75 multidisciplinary teams who attended the final year
of the Programme, completed questionnaires pre-course, and 6-8 weeks post-course.

Results

Across all team members, the main sources of job satisfaction related to working in
multidisciplinary teams; whilst feeling overloaded was the main source of job stress.
Surgeons and clinical nurse specialists reported higher levels of job satisfaction
than team members who do not provide direct patient care, whilst MDT coordinators
reported the lowest levels of job satisfaction and job stress. Both job stress and
satisfaction decreased after participating in the Programme for all team members.
There was a small improvement in team performance.

Conclusions

Participation in the Development Programme had a mixed impact on the working lives
of team members in the immediate aftermath of attending. The decrease in team members'
job stress may reflect the improved knowledge and skills conferred by the Programme.
The decrease in job satisfaction may be the consequence of being unable to apply these
skills immediately in clinical practice because of a lack of required infrastructure
and/or equipment. In addition, whilst the Programme raised awareness of the challenges
of teamworking, a greater focus on tackling these issues may have improved working
lives further.

Background

The National PELICAN Multidisciplinary Team Total Mesorectal Excision (MDT-TME) Development
Programme was a unique team-based residential training course attended by colorectal
multidisciplinary team members across England. The Programme originated as a series
of workshops funded by Macmillan Cancer Support. It was designed to teach surgeons
the technical skills to complete total mesorectal excision (TME) by live demonstration
of the surgery using video conferencing facilities, and thereby aimed to improve the
quality and usage of TME surgery. The success of these initial workshops led to the
NHS commissioning a fully multidisciplinary programme for all members of colorectal
multidisciplinary teams[1]. The demonstration of TME remained central to the Development Programme which also
aimed to provide education about relevant aspects of radiology, histology, oncology
and nursing.

We took the opportunity to evaluate the impact of participating in this national team-based
course on the working lives of colorectal team members. Underpinning this study was
the drive to tackle the high levels of poor mental health reported among UK cancer
doctors. In 2002 the estimated prevalence of psychiatric morbidity (GHQ-12 scores
≥4) among UK hospital consultants was 33% compared with 27% in 1994, according to
a national cohort study[2,3]. This deterioration in mental health over an eight year period was especially marked
in clinical and surgical oncologists and explained by increased job stress without
a comparable increase in job satisfaction. Similarly high levels of poor mental health
have recently been reported amongst colorectal surgeons and nurse specialists in the
UK NHS[4]. On the basis of findings that MDT working may be beneficial to the mental health
and working lives of team members[5], we evaluated the impact of participating in this novel MDT-based Development Programme
on levels of job stress, levels of job satisfaction and team performance of colorectal
cancer team members.

Methods

Study design and participants

We conducted a pre-post course evaluation involving all core team members from the
75 teams attending one of the 11 courses in the final year of the programme (September
2005 to October 2006). Core team members included consultant surgeons, oncologists,
histopathologists and radiologists, as well as clinical nurse specialists and MDT
coordinators.

Procedures

We ascertained team members through the PELICAN Cancer Foundation, the charity coordinating
the Development Programme. Pre-course questionnaires were posted and e-mailed to each
core team member approximately three weeks before each course, with a reminder two
weeks later. Post-course questionnaires were sent four weeks after each course, with
reminders sent six and eight weeks post-course. Consent to participate in the study
was assumed by return of a completed questionnaire. Confidentiality was maintained
by the allocation of a unique identification number, necessary for matching pre- and
post-course responses. Approval for this study was granted by South East Research
Ethics Committee and by the Trust Research and Development Department for each multidisciplinary
team.

The Development Programme

In total, 35 courses were held from June 2003 to October 2006. 183 out of 186 colorectal
multidisciplinary teams in England attended (1639 delegates in total). Courses were
held on a monthly basis and an average of seven teams attended each course.

Each course lasted two days, over which time team members received education about
the management of rectal cancer from national leaders in the field. Central to the
course was the opportunity to observe live TME surgery with two-way discussion between
operating and lecture theatres using video conferencing facilities. There were also
seminars on the latest advances in imaging[6,7], pathology[8,9], pre-operative radio and chemo-radiotherapy[10], supportive care issues including stoma management, and the management of secondary
disease. One session was dedicated to the challenges of multidisciplinary team working.
This session was unique to each course and chaired by members of the teams in attendance.
Team members had the opportunity for social interaction throughout the course by virtue
of its residential nature, with overnight accommodation for two nights, together with
a course dinner.

Outcomes

Change in self-reported job stress, job satisfaction, and team performance between
pre- and post-course assessment.

Job stress and job satisfaction

We measured self-reported job stress and job satisfaction using an adapted version
of The Hospital Consultants' Job Stress and Satisfaction Questionnaire[11]. The resulting study-specific questionnaire comprised items common to all multidisciplinary
team members (46 items related to job stress and 44 items related to job satisfaction)
and items relevant only to team members who provide direct patient care: surgeons,
oncologists and clinical nurse specialists (10 job stress items and 10 job satisfaction
items). See additional file 1 for job stress and satisfaction questionnaire.

Additional file 1.Adapted version of the hospital consultants' job stress and job satisfaction questionnaire. The questionnaire used to assess cancer team members' job stress and job satisfaction.

Job stress and satisfaction item scores: Each questionnaire item was rated according
to the extent it had contributed to an individual's total job stress or total job
satisfaction on a scale from 0 (not at all) to 3 (a lot).

Job stress and satisfaction sources scores: Factor analysis was used to explore the
grouping of individual stress and satisfaction items. All job satisfaction items aggregated
to one of seven main sources of satisfaction. Most job stress items aggregated to
one of eight main sources of job stress. Three job stress items did not aggregate
to a main source of job stress: 'feeling poorly paid for the job you do'; 'being required to provide routine clinical
NHS services outside of normal working hours' and 'disruption to home-life due to on-call work'. Job stress in relation to these items is included in the calculation of total job
stress but is not reported individually. Scores for the main sources of job stress
and job satisfaction were calculated by summing ratings given to the individual items
that aggregated to each source and were standardised (on a scale of 0-100). For each
score presented, the higher the score the higher the level of job stress or job satisfaction.

Total job stress and satisfaction scores: Total job stress and job satisfaction scores
were calculated by summing ratings given to all job stress and job satisfaction items
respectively. Scores were standardised (on a scale of 0-100) to aid comparison between
team members who did and did not provide direct patient care.

Team performance

Key aspects of team performance were measured the Aston Team Performance Inventory[12] (ATPI). Each team member rated 33 statements on a five-point scale from 'Strongly
Disagree' to 'Strongly Agree'. Total team performance scores were calculated by aggregating
responses to all 33 statements. Individual statements also aggregated to one of six
domains of team-working (table 1). Scores were standardised to enable comparison across domains. The ATPI is designed
for use as a team-level measure and therefore for each team in the study, the response
from individual members was averaged to give team-based total and domain scores.

Table 1. Impact of participation in the MDT-TME Development Programme on job stress, job satisfaction
and team performance

Pre-course expectations of the Development Programme and reported adequacy of skills
training for effective multidisciplinary team working

At the pre-course assessment, team members completed an open-ended question: 'What are you hoping to gain from the PELICAN MDT-TME Development Programme?' At that assessment team members also reported whether they felt adequately trained
in communication skills, teamworking skills, handling complaints from patients and
relatives, and team leadership.

Statistical Methods

We assessed the impact of participation in the Development Programme on job stress,
job satisfaction and team performance by analysing responses from team members who
responded to both pre- and post-course questionnaires (n = 333). Analysis of team
performance excluded one team as only one member responded to both pre- and post-course
questionnaires.

We used repeated measures ANOVA to assess the impact of participation in the Development
Programme on team members' job satisfaction and job stress (total levels and individual
sources) and team performance. Due to the exploratory nature of this study no adjustment
was made for multiple testing. Analysis was conducted using SPSS v.15 and R v.2.6.0.

Responses to the pre-course open-ended question about team members' expectations of
the Development Programme were read and main themes described independently by four
members of the research team. Once themes were agreed, one member of the research
team coded each response according to the agreed framework.

Results

Participant flow

Between September 2005 and October 2006, 568 team members from 75 teams participated
in the Development Programme at one of 11 courses. 464/568 (82%) team members responded
to the pre-course questionnaire and 367/568 (65%) to the post-course questionnaire.
A total of 333 team members (59%) responded to both pre- and post- course questionnaires.
The average number of respondents per team was 7 (range 1 to 10).

Characteristics of team members

Team members who completed both pre- and post- course questionnaires and those who
were lost to follow-up had very similar baseline characteristics, including having
similar levels of total job stress and job satisfaction (table 2). 104 team members participated in the Development Programme but did not complete
either pre- or post- course questionnaires. Of these, 67 (65%) were male; 46 (45%)
were surgeons and 21 (20%) were clinical nurses specialists.

Table 2. Demographic and professional characteristics of colorectal team members

Over half of the team members who participated in the evaluation of the Programme
were clinical nurse specialists or surgeons. Overall, the proportions of male and
female team members were similar, but over 90% of MDT coordinators and clinical nurse
specialists were female, whereas 90% of surgeons and 79% of radiologists were male.

Most surgeons and nurses were core members of only one multidisciplinary team, but
the majority of oncologists, radiologists and histopathologists were core members
of between two and four teams. Five percent of team members were core members of between
five and nine different teams; over half of these were oncologists.

Job stress and job satisfaction among colorectal cancer teams members at the pre-course
assessment

Among all team members 'feeling overloaded with work and impact on home life' was the most frequently reported source of job stress. 'Dealing with angry or blaming patients/relatives' was associated with similarly high levels of job stress amongst team members who provide
direct patient care (table 1). Across the professional groups surgeons reported the highest total job stress although
only significantly higher than MDT coordinators. MDT coordinators reported the lowest
job stress; significantly lower than all other professional groups (F5,327 = 4.9, p < 0.001). This pattern of differences in levels of total job stress across
the professional groups was repeated for each of the individual sources of job stress
(table 3).

Table 3. Impact of participation in the MDT-TME Development Programme on job stress and job
satisfaction by professional group

The highest levels of job satisfaction were reported by team members who provide direct
patient care and related to 'having good relationships with patients' and 'providing quality care to patients'. Across all team members 'working in a multidisciplinary team' and 'providing better care from working in a multidisciplinary team' were the predominant sources of job satisfaction (table 1). Surgeons and clinical nurse specialists reported the highest job satisfaction;
significantly higher than all other team members except oncologists. MDT coordinators
reported the lowest satisfaction; significantly lower than all other team members
(F5,326 = 16.5; p < 0.001). As with job stress, the pattern of job satisfaction levels by
professional group for the individual sources of job satisfaction was similar to the
pattern for total job satisfaction (table 3).

Impact of the Development Programme on job stress, job satisfaction and team performance

Across all team members, levels of total job stress decreased after participation
in the Development Programme (table 1). Levels of job stress decreased in six out of the eight individual sources (table
1). The decrease in total job stress was similar across all professional groups, as
was the decrease in relation to seven of the eight individual source of job stress
(table 3).

Levels of total job satisfaction also decreased after participation in the Development
Programme (table 1). Levels of job satisfaction decreased in four out of the seven individual sources
(table 1). The decrease in total job satisfaction and each individual source of job satisfaction
was similar across each professional group (table 3).

There was a small increase in team performance scores after participation in the Development
Programme. This was mostly accounted for by an increase in one aspect of team performance:
the extent to which the team reflected on their objectives and the way their team
was working (reflexivity; table 1).

Team members' expectations regarding the Development Programme

278 (83%) team members responded to the pre-course question about their expectations
of the Development Programme. The majority (240/278; 87%) gave a response that aggregated
to one of two main themes:

• To assess or improve their team working (n = 206, 74%): to assess their team working
in relation to others; or improve their team working (e.g. improve relationships within
the team, increase efficiency, manage conflict or gain a better understanding of other
team members' roles):

'Reassurance we are working together effectively and that our discussions are broadly
in line with national thinking'

'How to make the MDT more effective, efficient and professional with more input from
all members'

'An increased awareness of the responsibilities of the other disciplines'

'I hope that as a result of the Programme our team may become more cohesive and be
more functional, respectful and supportive'

• To improve their knowledge (n = 80, 29%): to be educated about best practice, latest
advancements, and training or learning specific to their role.

'To improve my knowledge and skills in colorectal cancer management'

'To improve my skills and understanding of MRI staging of rectal cancer and to improve
the quality of the imaging'

Prior to attending the Development Programme, three quarters of team members felt
adequately trained in communication skills but this varied from 86% of nurses to only
just over half of radiologists (table 4). Two-thirds of team members felt adequately trained in teamworking skills. Less
than 40% of respondents felt adequately trained in dealing with complaints, with particularly
low proportions of radiologists (19%) and MDT coordinators (16%) feeling adequately
trained. Less than a third of team members felt adequately trained in team leadership.

Discussion

For the colorectal team members we evaluated, participating in the MDT-TME Development
Programme was associated with a decrease in average levels of job stress and job satisfaction
six to eight weeks post-course. Team members also reported a marginal improvement
in team performance. The magnitude of the decrease in team members' levels of job
stress and job satisfaction was similar to the increase in job stress reported by
UK hospital consultants between 1994 and 2002 using the same measures[3]. The increase in job stress explained a five percent increase in prevalence of estimated
psychiatric morbidity among UK hospital consultants over that time period (from 27%
to 32% with GHQ-12 scores ≥ 4). This suggests that the impact of the Development Programme
on the well-being of colorectal team members is meaningful. The improvement in team
performance scores was mainly explained by a change in the extent to which teams reflected
on their teamworking. This has face validity given the nature of the Programme. Its
importance is however difficult to interpret as the Aston Team Performance Inventory
has yet to be validated against measures of the effectiveness of multidisciplinary
teams including the mental health of team members.

These findings are challenging to interpret. The decrease in team members' job stress
may reflect the improved knowledge and skills that the Development Programme conferred.
The decrease in job satisfaction may be the consequence of being unable to apply these
newly acquired skills in the immediate aftermath of the Development Programme because
of a lack of required infrastructure and/or equipment. Early reports suggest that
attendance at the Development Programme has improved clinical practice, including
increased usage of MRI preoperatively (Brown, personal communication, 27.05.10); improved
quality of reporting for radiology and increased lymph-node harvest (Yorkshire Audit
Data, Quirke, personal communication, 08.06.10). An internal evaluation of the impact
of the Development Programme on clinical practice 6-12 months after participation[13] also reports improved usage and reporting of MRI subsequent to attendance, as well
as the adoption of new network-wide policies and protocols. However, some teams also
reported being unable to implement some of the recommendations of the Programme due
to workforce shortages. These included dual consultant operating for difficult cases
and not having an MDT coordinator or clinical nurse specialist as part of the team.

Across all team members the main sources of job satisfaction related to working in
a multidisciplinary team and providing better patient care as a result of multidisciplinary
teamworking. This finding is consistent with findings from a national survey completed
by over 2000 MDT members in England, of whom 90% agreed that MDT-working is beneficial
to the mental health and wellbeing of team members, and 81% agreed that being an MDT
member improves job satisfaction[14]. The perception that teamworking improves patient care fits with the emerging evidence
that multidisciplinary teams are beneficial in terms of disease management and clinical
outcomes[15].

The levels and nature of job stress and satisfaction among hospital consultants has
already been well described[2,3] but this study provided a unique opportunity for comparison across all core colorectal
members of multidisciplinary teams. We found that clinical nurse specialists reported
similarly high levels of job stress as their medical colleagues. These high levels
for nurses may reflect a lack of clarity about the content and boundaries of their
job leading to excessive expectations from others[16-19]. They also reported high job satisfaction which is likely to be derived from spending
most of their working time delivering direct patient care[16], as well as the positive impact on their professional status and esteem of being
recognised as a core member of the multidisciplinary team in recent cancer policy.
Having professional status and esteem has been shown to be a key source of satisfaction
for hospital consultants[2,3]. MDT coordinators, who prepare and organise the multidisciplinary team meetings,
have a relatively new and rapidly expanding role[20]. The importance of MDT coordinators for effective MDT working has been acknowledged[20,21]. However, their low job stress and low job satisfaction suggests the need to standardise
and professionalise their work[22].

Strengths of this study include the response from almost 60% of team members from
a third of all colorectal cancer teams in England to both pre- and post-course questionnaires.
We received completed questionnaires from 82% of delegates pre-course and found no
difference in total job stress and satisfaction scores between those who responded
to follow-up and those who did not. We also used well validated job stress and satisfaction
measures, designed specifically for cancer health professionals[11]. The Development Programme reached almost every colorectal cancer team in England
and thus we chose a pre-post evaluation design as a randomised controlled trial was
not possible. Our evaluation focused on only the final year of the programme, which
was for pragmatic reasons. The relatively short timeframe of follow-up may have impacted
on the results. Benefits may have dissipated in the long-term. Alternatively, gains
in job satisfaction may have been reported in the longer term, once the challenges
of instigating the necessary service changes had been overcome.

The Development Programme was not intended to provide training in teamworking. Nevertheless,
a large proportion of team members attended the course with expectations that it would
do so. This study highlights significant shortfalls in the training that multidisciplinary
team members reported they had received in the skills that are key to effective teamworking,
namely in communication, teamworking, handling complaints and leadership. Amongst
these skills, effective leadership is arguably the most critical to the success of
teamworking, supported by the recommendation for standardised leadership training
by Lord Darzi[23]. To address the outstanding need for teamwork training identified by colorectal team
members, the methods used to improve communication skills in cancer health professionals[24] could be integrated into courses such as the Development Programme.

Conclusions

Participation in the Development Programme had a mixed impact on the working lives
of team members in the immediate aftermath of attending. Although challenging to interpret,
the decrease in team members' job stress may reflect the improved knowledge and skills
conferred to many participants by the Programme. The decrease in job satisfaction
may be the consequence of being unable to apply these skills immediately in clinical
practice because of a lack of required infrastructure and/or equipment. In addition,
whilst the Programme raised awareness of the challenges of teamworking, a greater
focus on tackling these issues in combination with enhancing clinical skills and knowledge
may go further to improve the working lives of cancer multidisciplinary team members.

Abbreviations

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

All named authors have agreed to the submission of this manuscript and participated
in this study to a sufficient extent to be named as authors. AJR and MR conceived
the idea for the study; CT was the study lead and wrote the first draft of the paper;
JS was the study coordinator; GC provided statistical support; CMc, AR and JD advised
on aspects of study design and interpretation of findings. All authors participated
in the critical revision of the article and have read and approved the final manuscript.

Acknowledgements

This study was funded by Cancer Research UK. We thank all of the colorectal cancer
team members who participated in this study; Dr Gina Brown, Mrs Celia Ingham Clark,
Maggie Vance, Theresa Porrett, Jill Dean and Sue Bates for their support in encouraging
participation; the PELICAN Cancer Foundation (Juliet Crawley, Julia Jessop; Chris
Beagley and all the faculty) for facilitating the evaluation; Sinead Drew, Jenny Harris,
Emma Teasdale and Chris Papadopoulos for assisting with data collection and analysis.

References

Jessop J, Beagley C, Heald RJ: The Pelican Cancer Foundation and the English National MDT-TME Development Programme.